Breast cancer preventive practices and associated factors among reproductive age women in Wadila District, North East Ethiopia: community based cross-sectional study

Background Cancer is one of the leading causes of morbidity and mortality worldwide. Among all cancer types, breast cancer stands out as the most common and is characterized by distinct molecular characteristics. This disease poses a growing public health concern, particularly in low and middle-income countries where it is associated with high mortality rates. Despite these challenges, there is a paucity of data on breast cancer preventive practices and associated factors among reproductive-age women in Wollo, Ethiopia. Hence, this study aimed to evaluate the level of breast cancer awareness, preventive practices, and associated factors among women of reproductive age residing in Wadila district, Wollo, Ethiopia in the year 2022. Method A cross-sectional community-based study involving 352 women of reproductive age in Wadila district was carried out between May and June 2022. Participants were selected using a systematic random sampling technique, and data analysis was conducted using Statistical Package for Social Science (SPSS) version 23 software. Logistic regression analysis was utilized to determine the odds ratio for variable associations, with statistical significance set at p < 0.05. Result The prevalence of breast-examination among women of reproductive age was determined to be 40.1% (95% Interval [CI]: 34.94–45.18). Factors such as educational status (Adjusted Odds Ratio [AOR]: 0.28, 95% CI: 0.13–0.6), income (AOR: 0.19, 95% CI: 0.11–0.33), and family history of breast conditions in reproductive-age women (AOR: 1.90, 95% CI: 1.08–3.34) were significantly linked to the practice of breast self-examination in this population. Conclusion The study highlighted a decline in regular breast self-examination among women of reproductive age. It revealed that the reduced frequency of regular breast self-examination was a prevalent concern among women in this age group and the broader community. Educational level, monthly income, and family history of cancer among women of reproductive age were identified as significant factors linked to the practice of regular breast examination.


Introduction
Cancer remains a significant global health challenge, contributing to high rates of illness and death worldwide.Data from the International Agency for Research on Cancer (IARC) indicates that there were approximately 14 million new cancer cases reported in 2012 [1].Among these cases, breast cancer stands out as the most commonly diagnosed malignant tumor in women and the second leading cause of female mortality globally [2].This disease is characterized by distinct clinical, pathologic, and molecular features [2,3].
The prevalence of breast cancer poses a growing public health concern, particularly in low and middle-income countries where it is a leading cause of mortality [3].Despite efforts to address risk factors and promote prevention, there is no population or woman globally who is truly immune to the possibility of developing breast cancer [2].The incidence of breast cancer has now surpassed that of lung cancer, with an estimated 2.3 million new cases worldwide [4].
In Lebanon, the median age at which breast cancer patients present is 49 years, underscoring the importance of early detection and intervention [4].While breast cancer was historically more common in developed nations, its impact has now spread to developing countries, posing a significant threat to public health [3].Alarmingly, nearly half of all breast cancer cases and over half of related deaths occur in low and middle-income countries, highlighting the urgent need for improved prevention and treatment strategies on a global scale [3].
The number of new cancer cases in Ethiopia is on the rise, with breast cancer being the most common type of cancer among women, accounting for 33% of female cancers and 23% of all cancers in the country.Breast cancer has emerged as a leading cancer among Ethiopian women, with an age-adjusted incidence rate of 41.8 per 100,000 women.In 2012, an estimated 12,956 new cases of breast cancer were reported in the country [5].A study conducted at Tikur Anbessa Specialized Hospital Radiotherapy Center revealed that breast cancer is the second most prevalent malignancy, representing 27.8% of all cancer cases referred to the hospital.The healthcare system in Ethiopia faces challenges in managing the prevention and treatment of cancer due to limited resources and a focus on addressing communicable diseases like HIV, malaria, and tuberculosis [6].
Raising awareness about breast cancer plays a crucial role in determining when patients seek medical help for the disease [7].Studies indicate that women's knowledge and practices related to breast cancer prevention and management can greatly influence their decision to seek medical assistance [8].Utilizing screening methods for early detection of breast cancer is a key strategy in reducing mortality rates associated with the disease [9].Detecting breast cancer at an early stage allows for prompt treatment before it spreads, leading to better outcomes.Achieving early diagnosis involves enhancing cancer awareness, encouraging active participation in healthcare, ensuring accurate clinical evaluations, obtaining proper pathological diagnosis, staging the disease accurately, and enhancing access to healthcare services [10].
Timely identification and diagnosis of cancer play a vital role in enhancing treatment success rates, emphasizing the significance of promoting awareness about symptoms of the disease.It is essential to grasp the extent of understanding and preventive measures concerning breast cancer among women of childbearing age to minimize its effects.In Ethiopia, there is a dearth of extensive information on breast cancer awareness and preventative actions in this specific group.The insufficient research conducted in this domain underscores the necessity to address this knowledge disparity.Hence, our research endeavors to evaluate the awareness, preventative practices, and influencing factors related to breast cancer among women of reproductive age in Ethiopia.

Study area and period
The research was carried out in Wadila district, an administrative woreda located in the North Wollo zone between April 22 and June 20, 2022.The district is situated 120 km northeast of Woldia and 320 km northeast of Bahir Dar.It is home to a population of 136,407 individuals spread across 24 rural and 2 urban kebeles.Of this population, 50.2% are female, and there are 32,165 individuals of reproductive age.The district is served by six health centers and one district hospital providing essential healthcare services to the community.

Study design
We utilized a community-based cross-sectional study design to examine reproductive-age women living permanently in the Wadila district.The sample consisted of reproductive-age women residing in Wadila district throughout the study duration.

Eligibility criteria
We included all women of reproductive age who lived permanently in the Wadila district and those who were present during the data collection.Women of reproductive age with visual, hearing, or speech impairments, as well as those with a history of breast cancer, were excluded from the study.

Sample size determination
The sample size was determined using the single population proportion formula, assuming the proportion of females who practiced self-breast examination (SBE) were.
Where; n = sample size required.α = the level of significance (5%).Za/2 = the value of Z (the standard normal distribution value) at the selected level of.Significance = 1.96.p = proportion of females who practiced SBE were 68%, Adding 5% non-response rate, the sample size becomes 352.

Sampling technique
There are 26 kebeles in the district and five of them were selected and included in the study by using random sampling technique.The numbers of households from each kebeles were determined based on their population size using a systematic random sampling technique with independent sampling intervals (kth value) applied to each kebele.Here, the sample size was also allocated proportionally according to the number of households in each selected kebele.Only one individual women in each household was selected and included in this study.
If more than one eligible woman were found in a single household, we selected only one of them by lottery method.

Data collection procedure
The data was collected by using a structured and selfadministered questionnaire that was designed by reviewing previous similar peer-reviewed published studies [12][13][14] and administered by interviewers.The questionnaire was pre-tested before the actual data collection and evaluated by research team to assess the content validity.The questionnaire consisted of all the variables that can meet the objectives of the study which are related to socio-demographic characteristics, substance use, known medical illnesses, knowledge, and practice regarding breast cancer prevention practice and early detection of risk factors.

Operational definition
Good practice of breast cancer prevention Those who carried out SBE practice a week after each menses using their palm and middle three fingers, or at least one clinical breast examination, or at least one mammography checkup in their life time [15].

Good knowledge about breast cancer early detection methods
We considered our participants as having good knowledge if they answered more than or equal to the mean score of knowledge assessment questions in our study [12].

Knowledge of women on breast cancer risk factors
This part was assessed by using reference guidelines of the American Cancer Society [15].Our participants were said to have good knowledge if they answered more than half of the questions assessing their knowledge on risk factors of breast cancer.

Dependent variables
Knowledge and level of practice of breast cancer prevention methods were considered as dependent variables while independent variables include socio-demographic factors (age, religion, marital status, level of education, occupation), life style factors (exercise, diet, substance use), reproductive and medical history (pregnancy status, family history of breast cancer, history of any breast disease, history of contraceptive, and comorbidity).

Data quality control
To maintain data quality, three data collectors who were health professionals (clinical nurses) were selected based on their experience in data collection and they were trained for 2 days on the objectives of the study, interview techniques, and ethical considerations during data collection.The questionnaire was properly developed by the research team by reviewing different kinds of previous peer-reviewed published articles [12] according to the specific objectives.The questionnaire was first prepared in the English language and translated into the local "Amharic" language to facilitate communication.The collected data was revised and checked for mistakes, legibility of handwriting, completeness, and consistency by the researchers daily during data collection before data entry and statistical analysis.Any mistake or ambiguity was cleared on the spot.

Data analysis procedure
Data analysis involved checking for completeness, coding, entry into Epi Data version 3.1, and export to Statistical Package for Social Science (SPSS) Version 23 for summarization and analysis.Descriptive statistics such as frequencies, means/medians, and proportions were used.Variables with a p-value < 0.25 in bivariable logistic regression were included in a multivariable model to identify independent associations.Adjusted odds ratios with 95% confidence intervals were reported, with a significance level of p < 0.05.

Ethical clearance
Ethical approval was obtained from the Zemen Post Graduate Coordinating Program Ethics Review Committee, with cooperation letters secured from the Wadela District Health Office and kebele administration offices.Informed consent was obtained from each study participants before data collection, ensuring confidentiality by removing any identifiable information.For those study participants who were less than 18 years of age, the informed consent was obtained from their parents or care givers.

Sociodemographic characteristics of the reproductive-age women
A total of 23.9% of women in the study fell within the age group of 30-34 years, with 57.4% residing in rural areas.Additionally, 61.1% of the women identified as followers of the Orthodox religion, while 84.1% belonged to the Amhara ethnic group.Among the participants, 35.2% had completed secondary education, and 27.8% were engaged in farming activities (Table 1).

Medical history and lifestyle conditions of reproductiveage women
Regarding the health history, 13.6%, 10.2%, and 9.9% of the participants reported a history of hypertension, diabetes, and other chronic diseases, respectively.Furthermore, 3.7% of them had a family history of breast cancer, and 13.9% had experienced other breast diseases.Substance abuse history was also reported by 15.6% of the subjects, while 33.2% engaged in regular physical exercise (Table 2).

Knowledge of reproductive-age women about breast cancer, its risk factors, and symptoms
The study revealed that 65.3%, 86.6%, and 69.0% of participants had poor knowledge about breast cancer, its risk factors, and symptoms, respectively.Only 40.1% (95% CI: 34.94-45.18)practiced breast checkups, with just 91.49% of them performing self-examinations.The initiation of breast examination typically began at age 30 and above for 39.0% of women (Table 3).4).

Discussion
The study revealed that the overall rate of lifetime regular breast examination among reproductive-age women in Wadila District was 41.1% (95% CI: 34.94-45.18).Among those who underwent regular breast examinations, 91.49% practiced SBE.This percentage is concerning given the high prevalence of breast cancer, a leading chronic disease that requires early detection and All the variables are continuous so that they are presented as number and percent intervention [16].These findings align with a previous study conducted among reproductive-age female healthcare workers in Iran, which also reported low consistency in SBE practices among employed women in health organizations [17].Similarly, a study among reproductive-age female students at Debre Berhan University found that only 28.3% of participants had performed SBE [18].These results underscore the importance of raising awareness and promoting regular breast examinations, particularly SBE, among reproductive-age women to improve early detection and management of breast cancer.However, the results of this study differ from those of a previous study conducted among female tertiary students in Ghana, which reported that 73.0% of the participants had practiced SBE at least once [19].The discrepancy in findings may be attributed to the inclusion of both educated and non-educated women of reproductive age in our study, who may be less inclined to engage in breast examinations compared to their educated counterparts.Additionally, our findings contrast with those of a prior study in Ethiopia, where the prevalence of SBE was only 4.3%, significantly lower than our observed rate [14].This inconsistency might be due to the possibility that women in our study had greater awareness of breast cancer, as it is a rapidly increasing health concern within the community [3] and a topic have been widely discussed from the previous to the current time, leading to increased recognition and engagement with breast examination practices.
The educational status of women was identified as a significant factor influencing the frequency of SBE over their lifetime.Multiple logistic regression analysis in this study revealed that reproductive-age women who had completed College/University were more likely to engage in SBE compared to those who were illiterate.This finding aligns with research conducted among female tertiary students in Ghana, which showed that fourth-year students were more likely to practice SBE than first-year students [19].Additionally, our results are consistent with a previous study in Sweden that examined factors affecting women's engagement in SBE [20].A study in Addis Ababa, Ethiopia, also found a statistically significant correlation between women's educational status and SBE [14].However, our findings contrast with a study among reproductive-age female students where only about 3.5% reported engaging in lifetime breast examinations [18].Similarly, a study in Southern Ethiopia reported an overall magnitude of lifetime breast examination at 34.3%, which differs from our findings [21].These discrepancies may be attributed to differences in the academic status of participants across the various studies.
The income level of the study participants emerged as a significant factor influencing the adoption of SBE.Our study revealed that reproductive-age women who were above the poverty line were more likely to engage in SBE compared to their counterparts.This finding is corroborated by a previous study conducted in Sweden [20].Additionally, our results align with other studies conducted worldwide among reproductive-age women [22][23][24].The findings of our study are also in line with a previous study conducted in Ethiopia [14].
Another factor significantly associated with the practice of SBE among reproductive-age women was family history of cancer.This finding is inconsistent with findings from various previous studies [22,25].Besides, our results contrast with the a previous study conducted among reproductive-age females in Mexico, which reported no significant difference in SBE practice between women with and without a family history of breast cancer [26].This discrepancy may be attributed to the genetic nature of cancer, as it is known to be hereditary [27].The genetic diversity of the reproductive-age women in our study compared to those in Mexico may account for the observed inconsistency.

Strength and limitation of the study
The study's key strength lies in its originality, as it sheds light on the assessment of breast cancer knowledge level, its preventable practices, and associated factors among reproductive age women in Ethiopia.This serves as a foundational reference for future in-depth studies.However, the study encountered some limitations like it was difficult to take the responses of the participants since the residents of the community both in the rural and urban areas were ashamed to participate in face-to-face interview and provide the appropriate responses for some questions.Thus, some sort of social bias might be present even though the survey was done anonymously by arranging the female interviewer for those female study participants (reproductive-age women.The other limitation of this study was that it was a cross-sectional study, which could not determine the causal relationships.

Conclusion
In the present study, the magnitude of overall regular breast examination and particular SBE among reproductive-age women was subsided.This study found that the diminished regular breast examination was a widespread issue of reproductive-age women and the community at large as women are parts of the community.The current study found that there were different factors significantly associated with regular breast examination including educational status, monthly income, and family history of cancer among reproductive-age women.

IARC International Agency for Research on Cancer LMICs
Low and Middle-Income Countries SBE Self-breast examination

Table 1
Sociodemographic characteristics of reproductive-age women in Wadila District, Amhara Region, Ethiopia, 2022 All the variables are continuous so that they are presented as number and percent.Others include Protestants and Catholics for religion and Oromos and South Nations, Nationalities, and Peoples for ethnicity

Table 2
Medical history and lifestyle conditions of reproductiveage women in Wadila District, Amhara Region, Ethiopia, 2022All the variables are continuous so that they are presented as number and percent

Table 3
Assessment of knowledge of reproductive-age women about breast cancer, its risk factors, and symptoms in Wadila District, Amhara Region, Ethiopia, 2022

Table 4
Assessment of factors associated with regular SBE among reproductive-age women in Wadila District, Amhara Region, Ethiopia, 2022